64 - Drugs of misuse a summary

Drugs of misuse – a summary

Addictions and substance misuse CHAPTER 4 Drugs of misuse – a summary Urine testing for illicit drugs is routine on many psychiatric wards and in out-­patient settings and doctors’ offices. It is important to be aware of the duration of ability to detect drugs in urine and of other commonly used substances and of drugs that can give a false positive result. Some false positives are unpredictable (i.e. not related to chemical similarity), for example amisulpride can give a false positive for buprenorphine.1 False positive results are most likely with point-­of-­care immunoassay kits. If a positive result has implications for a patient’s liberty, and the patient denies use of substances, a ­second sample should be sent to the laboratory for definitive testing by liquid chromatography and mass spectrometry (LC-­MS). Table 4.26 gives a basic summary of the features of drugs of misuse.

Table 4.26  Summary of drugs of misuse. Most common mental state changes2 Withdrawal symptoms Duration of withdrawal Physical signs/ symptoms of intoxication Drug Amfetamine-­type stimulants8 Tachycardia, increased BP; anorexia, tremor, restlessness Fatigue, hunger, depression, irritability, craving, social withdrawal Visual/tactile/olfactory/ auditory hallucinations, paranoia, elation Benzodiazepines Sedation, disinhibition Relaxation, visual hallucinations, disorientation, sleep disturbance Anxiety, insomnia, delirium, seizures, visual/tactile/ olfactory/auditory hallucinations, psychosis Cannabis10–16 Tachycardia, lack of co-­ordination, red eyes, postural hypotension Restlessness, irritability, insomnia, anxiety Elation, psychosis, perceptual distortions, disturbance of memory/judgement, twofold increase in risk of developing schizophrenia Cocaine Tachycardia/tachypnoea, increased BP/headache, respiratory depression, chest pain Fatigue, hunger, depression, irritability, craving, social withdrawal Euphoria, paranoid psychosis, panic attacks, anxiety, insomnia, excitement Duration of detection in the urine3,4 Other substances that give a positive urine test result5–7 Cough and decongestant preparations, bupropion, chloroquine, chlorpromazine, labetalol, promethazine, ranitidine, selegiline, large quantities of tyramine, tranylcypromine, trazodone and many others Depends on half-­life, mostly 48–72 hours Peaks 7–34 hours, lasts maximum of 5 days Desvenlafaxine may give a positive result for PCP9 Nefopam, sertraline, zopiclone, efavirenz Up to 28 days depending on half-­life of drug taken Usually short-­lived but may last weeks to months Passive ‘smoking’ of cannabis Single use: 3 days Uncertain, probably less than 1 month (longer in heavy users) Efavirenz, ibuprofen, naproxen Chronic heavy use: up to 30 days 12–18 hours Up to 96 hours Food/tea containing coco leaves, codeine, ephedrine/ pseudoephedrine

GHB/GBL Drowsiness, coma, disinhibition Sociability, confidence Tremor, tachycardia, paranoia, delirium, psychosis, visual/ tactile/olfactory/ auditory hallucinations Heroin (diamorphine) Pinpoint pupils, clammy skin, respiratory depression Drowsiness, euphoria, hallucinations Dilated pupils, nausea, diarrhoea, generalised pains, gooseflesh, runny nose/eyes Ketamine19–22 Increased HR, increased BP, palpitations, dizziness, abdominal discomfort, lower urinary tract symptoms, ataxia Fatigue, poor appetite, drowsiness, craving, anxiety, dysphoria, restlessness, palpitations, tremor, sweating Impaired consciousness, dissociation, hallucinations, ego diffusion LSD23 Variable Euphoria, introspection, illusions, pseudo-­hallucinations, altered sense of time, altered thought processes, altered perception of body, vivid recollections of significant memories Dilated pupils, moderate increase in HR and BP, flushing, sweating, hypersalivation, increased tendon reflexes 3–4 days 8–10 hours17 Not known Usually (and reliably) measured by LC-­MS18 Peaks after 36–72 hours Up to 72 hours Diphenoxylate, naltrexone, naloxone, opiate analgesics, food/ tea containing poppy seed, amisulpride, diphenhydramine, 4-­quinolones, tramadol Quetiapine 48 hours Ketamine: up to 2 days Norketamine: up to 14 days None N/A Up to 4 days Ambroxol, amitriptyline, brompheniramine, bupropion, buspirone, cephadrine, chlorpromazine, desipramine, diltiazem, doxepin, ergonovine, fentanyl, fluoxetine, haloperidol, imipramine, labetalol, lysergol, methylphenidate, metoclopramide, prochlorperaxine, risperidone, sertraline, thioridazine, trazodone, verapamil (Continued )

Methadone Pinpoint pupils, respiratory depression, pulmonary oedema As for heroin As for heroin but milder and longer lasting Peaks after 4–6 days, can last 6 weeks Up to 7 days with chronic use Quetiapine Other opioids such as nitazenes, fentanyls and oxycodone24,25 As for heroin, higher potency than heroin, faster onset of action, overdose common, seen as adulterants to street heroin As for heroin As for heroin As for heroin, faster peak Fentanyl: up to 72 hours Oxycodone: 2–4 days Nitazenes: variable Fentanyls – ascorbic acid Synthetic cannabinoid receptor agonists (SCRAs) Tachycardia, hypertension, red eyes, agitation Anxiety, agitation, aggression, psychotic symptoms, clouded consciousness Anxiety, sleep disturbance, headache Uncertain Difficult to detect using conventional screening methods because of chemical heterogeneity Too chemically diverse for urine screens, e.g. AB-­fubinaca, ADB-­fubinaca, AB-­chminaca 3-­methyl-­butanoic acid, ADB-­ chminaca and 5-­flouro-­PB-­22 are all classed as SCRAs Best detected and measured by LC-­MS26* Xylazine27 Bradycardia, hypotension, sedation, respiratory depression Rarely taken alone – usually an adulterant of opioids Sedation, muscle relaxation Hypertension, anxiety, irritability Unclear Unclear; probably a few hours Urine testing not common Unclear LC-­MS testing available28* *For more detail on cross-­reacting substances in urine testing, see Moeller et al. (2017).29 GBL/GHB, gamma-­hydroxybutyrate/gamma-­butyrolactone; HR, heart rate; LC-­MS, liquid chromatography and mass spectrometry; LSD, lysergic acid diethylamide; N/A, not applicable; PCP, phencyclidine. Table 4.26  (Continued) Drug Physical signs/ symptoms of intoxication Most common mental state changes2 Withdrawal symptoms Duration of withdrawal Duration of detection in the urine3,4 Other substances that give a positive urine test result5–7